Why is optimal perinatal culture important?
Further reading
What is culture?
‘Culture’ is the various components of institutional life which are shared across a workplace or organisation, such as the beliefs, attitudes and assumptions of their members; and their activities, such as their behaviours, practices and interactions. These normalised and shared ways of thinking, practising and behaving are what comes to be seen as appropriate and acceptable within that setting. The expressions of this culture are the social and cognitive ‘glue’ which bind members of that culture together, becoming both ‘the way people think around here’ and ‘the way things are done around here’1.
Healthcare culture
Healthcare culture is inextricably linked to quality of care, and is at the heart of improving patient outcomes through the potential to improve capacity, achieve better teamworking, reduce unwanted variation, and improve patient safety and experience of care. There is a consistently positive association between organisational culture and both clinical and operational outcomes including reduced mortality rates and bloodstream infection, as well as more positive workforce and patient experience1.
Failings in healthcare culture have frequently been cited in failures and scandals relating to adverse outcomes over several decades and cultural change is routinely prescribed as the answer2 3. Culture is also implicated in the reason why QI initiatives do not have the same impact when replicated across different settings4. However when improvements in culture are addressed both in clinical care and within the context of QI, better outcomes are observed5. The difficulty is that culture is multifaceted, somewhat nebulous and has historically been challenging to define and describe in any one unit or service. Culture can also be challenging to change and defies usual linear improvement strategies6. Implementing change is therefore complex and too often services are left with little understanding how to assess or address improvements.
Why is optimal perinatal culture important?
Team culture within Perinatal Optimisation activity is additionally difficult to address. The perinatal team is inevitably a dynamic cultural assortment of multiple and interrelated multiprofessional subcultures with variably shared assumptions, goals, values, beliefs, and behaviours. Care of women at risk of preterm birth is provided in complex settings and different geographical contexts sometimes extending to different networks, by a variety of sub-teams over what can be a prolonged episode of care, and is further complicated in that it involves the care of two individuals- the woman and her baby.
In perinatal care, variability in preterm outcomes cannot fully be explained by risk adjustment, engagement in continuous QI or adoption of potentially better practices, implying that culture has a key role in achieving optimal outcomes7. Neonatal units and maternity units however demonstrate wide variation in safety culture8 9.
Improving culture
While it is more usual to identify what aspects of culture contribute to error in maternity care, the features of a highly reliable and safe culture can be described within high performing delivery units. These features, which allow such services to function effectively and flexibly, necessarily operate in synergy and include: a commitment to safety and improvement at all levels; technical competence, supported by formal training and informal learning; teamwork, cooperation and positive working relationships; reinforcing of safe, ethical and respectful behaviours; multiple problem-sensing systems used as basis of action; systems and processes designed for safety and regularly reviewed and optimised; effective coordination and ability to mobilise quickly10.
Culture has also been studied in neonatal care. NICUs who demonstrate high proficiency in achieving better outcomes can be shown to foster a culture which prizes teamwork, patient safety, sustained learning opportunities as well as staffing models which encourage problem solving and wider involvement in QI activities11-14. These elements of neonatal team culture, described as the ‘secret sauce’ can contribute to success or failure of improvement programmes in any one particular context 15 16 and are also implicated in the longevity of that change over time17.
Such elements of culture which are closely linked to high proficiency outcomes across perinatal teams can become a charter for excellence for other maternity units and perinatal teams.
Importantly, by addressing deficits in perinatal team culture by creating safety roles, safety oversight, interdisciplinary teamwork training and standardisation of evidence-based care, improvement in a range of outcomes can be observed. These include safety climate scores18 19 and the adverse outcome index 20. Factors relating to team culture have been frequently implicated in the outcomes of perinatal optimisation implementation. Interventions which have addressed key cultural weaknesses have resulted in enhanced implementation of antenatal steroids 21-23, place of birth24 25, magnesium26 27, and optimal cord management28 29. Ultimately, there is improvement of preterm outcomes when modification of both neonatal team culture and the quality context are addressed in parallel with clinical QI programmes30 31.
In line with BAPM endorsed recommendations, embedded and specialist neonatal psychologists can support positive culture change; having an understanding of the psychological processes that promote changes in beliefs, attitudes and behaviours and the training and skills to facilitate this amongst individuals, teams and systems.
In response to Better Births32 and reports from regulatory bodies such as the Care Quality Commission (CQC) which highlight concerns about suboptimal maternity culture, the Maternity Transformation Programme Board of NHSE/I is developing a programme of support to creating a culture of safety and continuous improvement across perinatal services. This complimentary resource will provide activities and suggest solutions, which can be used by perinatal teams in reflecting on their own culture and in improvement planning.